How much pain is "real?"

[fozzy40]

Just looking for thoughts and ideas...

I have a family member that has been suffering from chronic pain of unknown origin for more than 10 yrs. She has been through the ringer of specialists and no one can really seem to find anything. She complains of diffuse muscle (not joint) pain specifically in the forearms and quads. Pain was so excruciating that she has been basically home bound from the age of 50 until the present. Pain is dull and achy, intermittently present, no radiation. Alleviating factors include chiropractic manipulation and rest. Flairs brought about randomly. Pt is a retired RN (retired from pain) with no previous hx of psychiatric or mood disorder. Here's the kicker, she is able to move in spite of the pain when she needs/wants to which makes me feel like there is definitely a psychosomatic component. Pain is alleviated with TCA she is now taking and rest.

She is now starting to show signs of worsening depression (sleeping, irritable, crying.) I think that she has had some amount of clinical depression all these years, life stress triggered it 10+ years ago, some organic medical condition, and some portion of psychosomatic pain. She definitely adheres to the patient role and has been becoming more irritable and lashing out at the family. As a retired RN, she plays "I'm a nurse and I know medicine" card so compliance is definitely an issue.

I'm not really quite sure which came first: pain causing depression or vice versa. I want to believe in her pain but I honestly think that a majority of her pain is actually psychosomatic.

What do you do with this type of patient?

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[lobelsteve]

Start here:

http://archinte.ama-assn.org/cgi/content/full/163/20/2433

Check out Consultant Magazine insert/CME for an update article on the link between Depression and Pain.

Do not give up on a medical diagnosis to better explain the painful condition.

PMR, PM/DM, CTD-NOS, Myopathy, etc.

Or get lazy, call it FMS, and tell her to exercise and have a nice day (I see this too much in my area)

 

[drusso]

Her suffering is real and her pain is real. Remember the IASP's definition of pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience.

Her pain responds to TCA's which suggests that it is has a strong "central component." It sounds like her ability to "modulate" her pain is in dis-repair.

So...

Rule out all "organic" painful conditions. This involves "thinking like a specialist" which some times pain doctors don't do. No myopathy? No underlying rheumatic disease, etc...

Then, AVOID OPIOIDS at all costs. Opioids are not the solution for this kind of painful condition.

Switch from TCA to duloxetine or SS/SNRI.

Assess, diagnose, and treat any underlying sleep impairment. Non-restorative sleep exacerbates all chronic pain states.

Judicious use of physical modalities or manual medicine for symptomatic "flares."

CBT and/or ongoing psychological therapy or support for developing skills. Help the patient reframe her pain condition---it's like living with diabetes or high blood pressure. It's a lifestyle change.

 

[Doctodd]

i think nurses are the best patients(sarcasm).....just like we are. Id get her into a pool and doing some exercises....and sleep is key. Can anyone bring up the study where rats were kept awake for 2 weeks until they died of not getting any sleep?

T

 

[fozzy40]

Definitely not going to give up. Just starting to run out of options. The depression is starting to be the more of the problem know and is precluding her willingness to do ANYTHING. She sees no utility in exercise because the pain is too much, most medications she refuses to take because of the "side effects", and she also only takes medications that "she" thinks she needs despite physician advice. I also found out that she tested RF positive (unsure of the titer) but in no way is clinically an RF patient. Her physician actually ordered it because she asked her to and partly because her PCP has absolutely no idea what's wrong with her. Now that she has tested RF positive she clings to that DX despite further testing for confirmation.

I have brought up the suggestion about psychotherapy and going to a chronic pain group but has a million excuses not to go. Currently, she is shopping for docs with a "silver bullet" and is not willing to f/u with them if she doesn't "feel" better in 2 visits.

I need a new game plan...

Thanks for everyone's input

 

[SSdoc33]

sounds like your game plan is fine. you just need the players to stick to it.

i think this is the article where the canadian guy kept poking the med students for days on end so they wouldnt sleep, and saw what happened to them. goo!!!

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

 

[Ligament]

She is very clearly a maladaptive pain patient. She needs some serious pain psychology treatment to teach her this. There is also likely a component of sleep disorder; rule out sleep apnea or restless legs. There is a good body of evidence showing dramatically altered pain thresholds with even one night of disordered sleep (ie. REM or stage 3 and 4 sleep disruption).

Overall, however, what rings in my mind on this patient is she has some serious psychological issues that need to be addressed.

By the way, most nurses know NOTHING about chronic pain, so tell her to stop professing expertise about her issues. Heck, most physicians know nothing about chronic pain!

 

[Doctodd]

might as well try "The Secret". If it is good enough for Oprah, it should be good enough for her.....seriously.

T

 

[delicatefade]

Question: do any of you as pain specialists screen for rheumatologic conditions if suspected (as in the post above) or do you refer to rheumatology for that sort of thing?

 

[Disciple]

If I suspect something, I'll do a basic screen (CBC, ESR, RF, TSH, maybe plain films of the L-Spine/SIJ, etc.) and refer to Rheum if these start coming up positive.

 

[fozzy40]

Thanks for everyone's input. I'll definitely keep your ideas in mind and we'll see if things change.